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The patient was a 41 year old woman that was brought to the emergency department (ED) by her husband following seizure. According to the relatives accompanying her, the seizure was of tonic-clonic type, had occurred one hour before presentation to ED, and had lasted 3 minutes. The patient had been drowsy for about 15 minutes after the end of the seizure. She had no history of head trauma and did not mention headache, nausea and vomiting, fever, vision problems or others. On presentation, amnesia regarding the things that happened was evident. In her history, she had a generalized tonic-clonic seizure 4 years back, regarding which she had not done proper follow up for taking necessary diagnostic measures and had not been treated with anti-epileptic medication. She had a history of surgery for removing cold thyroid nodule 20 years ago and was under calcium treatment for 15 years but she had decided to stop taking her medications since 5 year ago. She did not have a history of alcohol or drug abuse. The patient was conscious and awake on presentation and did not have any specific clinical complaints. Her vital signs on presentation were as follows:Blood Pressure = 120/70mmHg, Pulse Rate = 68/minute, Respiratory Rate = 16/minute, O2saturation= 98% at air room, Oral Temperature= 37°C, and bedside blood sugar in the normal range.In head and neck examination, the surgery scar was seen in the thyroid region. Examination of the thyroid also showed a nodular surface in palpation. Examination of the heart, lungs, abdomen and extremities did not have pathologic findings. Neurologic examinations including evaluation of cranial nerves, sense and power of the muscles, cerebellar examination and deep tendon reflexes were normal. Based on the opinion of the in-charge physician, anti-epileptic drugs were not prescribed at this stage. Laboratory tests including complete blood cell count, liver function tests (LFT), and level of blood sugar (BS), sodium, potassium, calcium, phosphorus, magnesium, urea and creatinine electrolytes were ordered. Considering the full consciousness of the patient and stability of vital signs and clinical examinations, by taking safety measures and accompanied by a nurse, the patient was referred to the radiology unit to undergo a brain computed tomography (CT) scan, the results of which are shown in figure 1.

A 60-year-old female without any notable past medical or surgical history presented with redness, swelling, and pain at the base of her left fourth finger. Twelve hours before, she had cut the end of her finger with the tip of a pitchfork while mixing the compost in her garden. At the time of

An 88-year-old Thai man with recently diagnosed autoimmune hemolytic anemia (AIHA) was started on prednisolone at 40 mg/day and azathioprine at 50 mg/day 2 weeks prior to admission. He presented with watery diarrhea, a low-grade fever, and fatigue that had started 1 week prior. His vital signs

Answer: Pneumonia with lung abscess due to serogroup 10 Legionella pneumophila. The Gram stain of the bronchoalveolar lavage (BAL) fluid smear shows intra- and extracellular Gram-negative bacilli, suggestive of aerobic bacteria. Legionella pneumophila is usually described as a pleomorphic, faintly

Answer: Human African Trypanosoma. A molecular study using PCR with a blood sample confirmed the presence of Trypanosoma brucei gambiense in the blood. Examination of cerebral spinal fluid showed increased protein levels (161 mg/dl) and lymphocyte counts (112 cells/μl), indicating the involvement

Answer: A noctuid caterpillar. Due to the presence of the worm-like organism in the vomitus, the child's mother was concerned about a parasitic helminth infection; however, the organism was subsequently identified as a noctuid caterpillar (larva) ([2][1]). The overall morphology and size, together

Answer: Dermatophilus congolensis. This patient had pitted keratosis due to Dermatophilus congolensis, a Gram-positive bacillus first described in 1915 as a cause of contagious dermatitis in cattle in the Belgian Congo ([1][1]). This organism is associated with a range of skin diseases in cattle

A 26-year-old woman presented to her general practitioner with a 3-week history of nonhealing lesions over the right shin. She had returned from a holiday in Thailand 3 weeks prior and remembered numerous insect bites but could not specifically recall any bites over her shin. During her stay in

A 59-year-old male with a past medical history of chronic obstructive pulmonary disease, hyperlipidemia, and gastroesophageal reflux disease and a recent history of upper left molar pain and right-sided body numbness was found by his wife to be having seizure activity while asleep. Upon arrival to

Answer: Streptobacillary rat bite fever or Haverhill fever. A presumptive identification of Streptobacillus moniliformis was issued upon the basis of the isolate's morphology, cellular arrangement, and relative biochemical inertness. Sequencing of a 1,442-bp 16S rRNA gene fragment of the isolate

A 5-year-old male was referred to the Riley Hospital for Children for evaluation of limping and refusal to use his right hand. Prior to presentation, he had been intermittently ill for 3 weeks with symptoms that included recurrent fevers (39°C to 41°C), chills, and an erythematous, macular rash on

An 83-year-old man presented to our hospital with a 1-year history of progressive growth of an anal mass. The mass was infiltrating and elevated, its consistency was hard, and it was painless and pruritic. There was no history of fever, night sweats, abdominal pain, rectal bleeding, or constipation

Answer: Anal leishmaniasis. Giemsa-stained touch preparations of the anal biopsy material showed intracellular Leishmania amastigotes. The patient's serologic analysis result for Leishmania was positive. Colonic histology showed no Leishmania, and a bone marrow biopsy showed no significant findings

A 33-year-old man presented to the emergency department ED) with complaint of 2-day history of abdominal pain. His pain developed with gradual onset prominently in epigastric area after eating dried mushrooms. The pain was diffuse, persistent, radiating to the back and aggravated by meal. He had been tolerating only liquids and had complaints of nausea and vomiting. He had no history of diabetes mellitus, hypertension, alcohol consumption, malignancy, or prior surgery. On arrival his blood pressure was 128/72 mmHg, with a heart rate of 101 beats/minute and a respiratory rate of 20 breaths/minute. He was afebrile. Physical examination revealed diffuse abdominal distention, hyper-pitched bowel sounds, and tenderness more marked over the umbilicus with no guarding or rebound tenderness. A complete blood cell count showed the following: leukocyte count 12600 /mm3; segmented neutrophils 90%; hemoglobin level of 14 mg/dl; hematocrit 30%; and platelet 420000/µL. Other laboratory studies included: glucose 101 mg/dL; serum urea nitrogen 45 mg/dL; serum creatinine 2.0 mg/dL; sodium 148 mEq/L; potassium 3.1 mEq/L; serum glutamic oxaloacetic transaminase (SGOT) 38 U/L and lipase 30 U/L. Figure 1 shows patient’s plain upright abdominal X-ray as well as coronal and axial cuts of abdominal CT scan.

During the month of August 2013, an 8-year-old previously healthy boy was transferred from Mexico to San Antonio, TX, after 5 days of headache, fever, and nausea with associated photophobia and altered mental status. The patient had been spending time in Mexico, where he used river water for bathing

A 40-year-old man with no significant past medical history developed fever, dry cough, night sweats, chills, and malaise 1 week after hiking in the mountains in Michigan. He visited his primary care physician (PCP) and was treated with oral azithromycin for 5 days with no improvement. The patient

A previously healthy 22-year-old male was admitted to the intensive care unit following a motor vehicle accident. His injuries included a right subdural hematoma, subarachnoid hemorrhages, a left hemopneumothorax, a hemoperitoneum secondary to a splenic rupture, multiple rib fractures with flail chest, and fractures of the left scapula and left clavicle. The subdural hematoma was evacuated by means of a decompressive craniotomy on hospital day 1, and an external ventricular drain was inserted. A removal of the spleen was executed the day after. The patient's initial hospital course was complicated by a pneumonia due to Haemophilus parainfluenzae and Enterobacter cloacae, which was treated with cefotaxime for 7 days. On day 17 postcraniotomy, the patient developed a fever. Twelve blood cultures taken from the arterial catheter and one urine culture were negative. Chest and abdominal tomography showed no septic focus. A cerebrospinal fluid (CSF) sample was collected from the external collection bag while the external ventricular drain was in place. Analysis showed a protein level of 2.39 g/liter (range, 0.10 to 0.20 g/liter) and a glucose level of 3.8 mmol/liter (range, 2.7 to 3.9 mmol/liter), whereas the glycemic level was 6.4 mmol/liter, with 24 leukocytes/mm3 (90% neutrophils) and 9 erythrocytes/mm3, and no organism was seen on Gram stain. The cultures remained negative after 24 h and after 48 h of incubation. After 4 days, thin translucent pinpoint colonies were observed on a chocolate agar plate. Three other CSF samples collected from the external collection bag on days 19, 21, and 23 postcraniotomy were positive for the same organism, with increased numbers of white blood cells (62 cells/mm3, 70 cells/mm3, and 250 cells/mm3, respectively). In all, during hospitalization, among 21 samples of CSF collected from the external collection bag, 4 were positive for this organism. Gram stains of the colonies were negative. Microscopic examination revealed small colonies as shown in Fig. 1.

Answer: Invasive fungal infection of the right paranasal sinus demonstrating two distinct, adjacent morphologies consistent with a Mucorales (Zygomycetes) mold and a narrow, septate hyaline mold. Fungal culture of the debrided right paranasal sinus tissue grew Fusarium and Rhizopus species

A 54-year-old male from South Dakota with recently diagnosed acute myelogenous leukemia (AML) presented with right-sided facial pain associated with right periorbital swelling, diplopia, and bloody nasal discharge. He had received standard induction chemotherapy with cytarabine and idarubicin during

Answer: Intestinal spirochetosis. The colon biopsy specimen showed intestinal spirochetosis. The endoscopic appearance in intestinal spirochetosis tends to be nonspecific, ranging from normal to polypoid areas or erythema (1). A basophilic fringe of spirochetes can be seen attached to the luminal side of the colonic epithelium. These organisms are known to attach to the mature microvilli of mature colonic and rectal epithelia. The spirochetes appear as an accentuated brush border-like layer coating the microvilli of the superficial epithelium, often referred to as a false brush border. Typically, the diagnosis is made by a pathologist examining the biopsy specimen. A Warthin-Starry silver stain for spirochetes can highlight the organism (see Fig. 1C and D in the photo quiz). Intestinal spirochetosis in humans is caused predominantly by Brachyspira aalborgi and Brachyspira pilosicoli. This condition is thought to be most prevalent in developing countries (2), among homosexual males (3), and among individuals with human immunodeficiency virus (HIV) infection (3). These organisms are slow-growing fastidious anaerobes and thus are infrequently recovered from stool specimens. While the pathological significance of intestinal spirochetosis is unclear, this condition has been reported to be associated with chronic diarrheal symptoms, especially in HIV-positive individuals. Evidence suggests that invasion of the organism beyond the epithelium may be associated with symptoms that respond to metronidazole (3). Using CLSI guidelines for susceptibility testing of anaerobes, Brooke et al. tested 123 human isolates of Brachyspira pilosicoli, all of which were susceptible to metronidazole, with an MIC90 of 0.25 μg/ml (4). The introduction of PCR-based assays along with immunohistological methods over the past decade may provide the tools to allow us to study the epidemiology and clinical importance of this organism (5). (See page 3711 in this issue [doi:10.1128/JCM.00005-14] for photo quiz case presentation.)

Answer: Scedosporium prolificans . Scedosporium prolificans is a filamentous fungus that was discovered in greenhouse soil in 1974 ([1][1]). Scedosporium species are ubiquitous saprophytic fungi found in soil and polluted water. Infection is acquired following traumatic implantation or aspiration of

Answer: Histoplama capsulatum associated with granulomatous inflammation of the larynx . Histoplasma capsulatum is a dimorphic thermal fungus that is found in temperate zones and tropical humid areas where soils are acidic and rich in nitrogen. Fungal spores can be found in the soil of caves or

Answer: Acute tenosynovitis due to Streptomyces spp. Although initially reported negative, the Gram-stained smear from the intraoperative specimen was carefully reviewed and revealed a very small number of Gram-positive rods that had been missed on the first Gram stain examination. Despite the

Answer: Disseminated strongyloidiasis presenting with larva migrans or cutaneous strongyloidiasis. A repeated stool examination for ova and parasites revealed a few typical rhabditiform larvae (not shown); examination of a fresh sputum smear revealed no larvae. On hospital day 6, the patient

Answer: Plasmodium falciparum infection with hyperparasitemia. Plasmodium falciparum can be differentiated from other Plasmodium species on blood smear by the absence of forms other than ring trophozoites and/or the presence of rarely observed banana-shaped gametocytes. However, morphologically, P.

A 44-year-old woman was referred to our emergency ward for acute renal failure complicating an end-stage chronic renal insufficiency. The patient history was notable for type 1 diabetes starting at the age of 7, high blood pressure, and a kidney transplantation 18 years prior due to microvascular

The patient was a 23-year-old man referred to the emergency department (ED) with the chief complaint of palpitation. The patient experienced dizziness, cold sweating, and lightheadedness after getting up which started spontaneously. He had four episodes of the same problems in seven months ago that felt better after taking 10 mg propranolol. But, in the current episode his problem was not solved by the same medication. He had no history of smoking, substance abuse, medication use, congenital heart disease, syncope, previous surgery, chest trauma, or any other known medical problems. As well, he had no any positive history of the same problems in his family. The patients’ on-arrival vital signs were as follow: systolic blood pressure (SBP): 90 mmHg, pulse rate (PR): 150/minute, respiratory rate (RR): 14/minute, oral temperature: 37◦C, oxygen saturation 96% with nasal cannula and 100% oxygen, Glasgow coma scale (GCS) 15/15. He was not experienced any other concomitant problems such as ischemic chest discomfort, shortness of breathing, or sign of circulatory shock such as paleness, mottling, etc. On general physical examination the patients’ lung and heart sounds, four limbs pulses, and capillary refile were normal. As well, focused neurological and abdominal examinations did not have any positive finding. The patient underwent close cardiac, vital sign monitoring and electrocardiography (ECG). Figure 1 shows the on-arrival patients’ ECG. Atrial fibrillation (AF) was diagnosed by the corresponding physician and digoxin (!?) prescribed that led to severe lethargy, weakness, sweating, and bradycardia. Figure 2 shows the post mediation ECG of patient.

This is a photograph of Sarah Elizabeth Stewart, PhD, MD (1905–1976) (Figure), whose discoveries involving the murine polyomavirus with Bernice Eddy, PhD, propelled the then-reluctant field of oncology to pursue viral etiologies of cancer. Sarah Stewart was born on August 16, 1905, in Jalisco, Mexico, to an American engineer and Mexican mother. After moving with her family back to the United States at age 5, Stewart remained fluent in Spanish. In 1927, she graduated from New Mexico State University and in 1930, she earned an MS in Microbiology at the University of Massachusetts, Amherst. She worked at the National Institutes of Health (NIH) during 1935–1944, publishing 7 papers on anaerobic bacteria and completing a PhD from the University of Chicago in 1939. Figure Sarah Elizabeth Stewart (1905–1976). Source: Hobson-Huntsinger University Archives at New Mexico State University. In 1944, when Stewart requested support to study the link between animal tumors and viruses, the directors of the NIH Laboratory of Microbiology and the National Cancer Institute (NCI) refused on the grounds that the proposal seemed dubious and that she lacked appropriate qualifications. Rather than give up her passion to study viruses and cancer, Stewart resigned and became a bacteriology instructor at Georgetown University School of Medicine; there she audited classes, and after women were permitted to enroll, Stewart became their first woman graduate at age 39. After completing an internship in 1951, Stewart returned to NCI to launch her viral oncology research career. To understand Stewart’s role in catalyzing viral oncology research, it is necessary to recognize that until the 1950s, scientists dismissed the idea that viruses could cause cancer. It took many decades before the seminal contributions of several virologists studying cancers were appreciated, such as Peyton Rous’ 1911 discovery of the Rous sarcoma virus (which caused tumors in chickens), and discoveries of Richard Shope (rabbit fibroma) and John Bittner (mouse mammary carcinoma) in the 1930s. In 1951, Ludwig Gross described the transmission of leukemia in newborn mice by using a cell-free extract; in 1953, he reported parotid tumors in these mice. Even after Stewart confirmed Gross’s findings in 1953, the scientific community still did not acknowledge viral causes of mammalian cancer. Only after Stewart fulfilled Koch’s postulates in 1957, with the assistance of Dr. Bernice Eddy, did oncologists pay heed to viruses. Dr. Eddy had also trained as a PhD bacteriologist at the University of Chicago and since 1937, worked at the NIH Biologics Control Laboratories, in Bethesda, Maryland. In 1954, Eddy had been sidelined for whistleblowing about the presence of live virus in Jonas Salk’s inactivated polio vaccine (the infamous Cutter incident). So in 1956, when Stewart approached Eddy for assistance growing the agent causing parotid tumors in mice, Eddy readily agreed and the 2 women rapidly worked out the characteristics of the agent that was not referred to as a virus in their publications until 1959. Together they showed that the virus produced 20 types of mouse tumors and could cause tumors in other small mammals. At Eddy’s suggestion, the virus was dubbed polyoma, which means many tumors, and they named it the SE (Stewart–Eddy) polyomavirus. They also demonstrated that the virus causes cell necrosis and proliferation in cell culture, that it is highly antigenic, and that it leads to formation of specific antibodies in infected animals whether or not tumors develop. The results of their collaboration were picked up by a 1959 Time Magazine cover story, citing John Heller, then the NCI director, “the hottest thing in cancer research is research on viruses as possible causes of cancer.” Alan Rabson, a prominent member of the NCI Laboratory of Pathology, stated, “The whole place just exploded after Sarah found polyoma.” Stewart became medical director of the NCI Laboratory of Oncology and spent the remainder of her life researching several oncogenic viruses (e.g., Epstein-Barr virus). As a US Public Health Service Commissioned Officer, her scientific contributions to the study of viral etiologies of cancer earned her the Federal Women’s Award, presented by President Lyndon Johnson in 1965. In 1960, Eddy again found herself in hot water, this time for reporting her discovery of an oncogenic simian virus (SV40) in polio vaccine prepared from monkey kidneys. Stewart retired from the Public Health Service in 1970 to become a full professor of pathology at Georgetown University. She died of stomach cancer in 1976. Bernice Eddy described her as “a forceful individual who did not let anything stand in [her] way if she could help it.” Despite sex discrimination and a period in which several laboratory directors disparaged her wish to study oncogenic viruses, Stewart persisted with such enthusiasm that she managed to break through as one of the most influential scientists and cancer researchers of her time.

Differential diagnosis of genital lesions must include venereal and nonvenereal dermatosis. Atypical manifestations of common dermatosis exclusively over scrotum pose diagnostic challenge and histopathology plays a crucial role in such cases.

Patient was a 33-year-old woman underwent her first time cesarean section combined with spinal epidural anesthesia 5 days before and discharged the day after with good condition. She got severe headache with pain score about 8-9, 2 days after discharge from hospital. Her headache was severe, bilateral, pulsatile and almost likely sudden onset accompanied with nausea that mildly progressed after starting. She went to the hospital which her delivery was taken; with impression of Post Dural Puncture Headache (PDPH) 10mg IV morphine sulfate was administered totally and subsequently discharged home with relative decreased headache. The day after first headache attack, when she admitted in our Hospital, claimed that could not hold her baby for breast feeding. In minimental status examination, time disorientation was obvious but orientation to place and person was intact. In motor examination we found right side hemiparesis and also decreased right upper and lower limbs tone. Brain CT Scan and then MRI was performed and reveal massive cortico-subcortical hemorrhagic infarction on left parieto-occipital lobes. With attention due to significant nonhomogene occupying lesion, brain MRI with gadolinium and also MRV was per-formed.What is your doagnosis?

Answer: Mansonella perstans. A Wright-Giemsa-stained peripheral blood smear demonstrated an unsheathed microfilaria with nuclei extending to the tip of a blunt tail, characteristic of Mansonella perstans, measuring approximately 100 μm. M. perstans is transmitted by the Culicoides fly, endemic to

Answer: Actinobaculum schaalii. The Gram stain of material from the abscess showed many Gram-positive cocci and Gram-negative coccobacilli. The organism that grew in aerobic culture initially presented as a pleomorphic Gram-positive organism with both coccoid and rod-shaped forms. After extended

A 55-year-old man presented to the emergency department with complaints of a painful abscess on his inner right thigh that had been present for about 1 week. The patient was morbidly obese, with a significant medical history, including type 2 diabetes, hypertension, asthma, and previous abscesses.

A 66-year-old Caucasian male presented to the emergency department of Royal Perth Hospital with a 3-day history of fever, dyspnea, vomiting, and loose bowel movements. His past medical history included hypertension and gout. On examination, he was febrile, tachycardic, hypotensive, and tachypneic

A patient's wife called the Kaiser Permanente clinic and spoke to the advice registered nurse (RN) on behalf of her wife (the 56-year-old patient declined to come to the phone). The patient's wife stated that the patient had persistent fever and aches that had gotten progressively worse since the

Answer: Tomato seeds in a pleural biopsy sample after an emergency thoracotomy. At first glance, the objects resembled eggs of Schistosoma haematobium, but this tentative diagnosis was rapidly discarded, considering the size measurement of 3.7 mm. On closer inspection, the presence of a capsule and

A 23-month-old girl with relapsed acute myeloid leukemia (AML) was admitted in partial remission for matched-unrelated donor umbilical cord stem cell transplantation. She received intense pretransplant conditioning with cytarabine (on day 11 pretransplant [here referred to as day −11] to day −6

Answer: Enteric fever. Manual and automated phenotypic methods identified the lactose-nonfermenting blood culture isolate as a Salmonella species. Subsequent serotyping of the isolate by use of O and Vi group D antisera definitively identified it as Salmonella enterica subsp. enterica serovar Typhi

A 63-year-old Caucasian female with a history of Crohn's disease and recurrent gastrointestinal strictures requiring multiple surgeries, including end ileostomy, presented to our medical center in June 2012 with a 1-week history of fevers up to 104°F and rigors. She had also experienced acute

Answer: Weissella confusa. The diagnosis of bacteremia due to Weissella confusa was confirmed by 16S rRNA gene sequencing. The organism, based on the production of alpha-hemolysis, the Gram stain, and the catalase-negative reaction, was preliminarily reported as “Lactobacillus-like, identification to follow.” Repeat blood cultures were subsequently negative after removal of the peripherally inserted central catheter (PICC) and therapy switch from vancomycin to daptomycin. We believe that her bacteremia was related to the indwelling PICC, total parenteral nutrition (TPN) dependency, and the history of altered gut flora with multiple abdominal surgeries. W. confusa is a nonmotile Gram-positive, alpha-hemolytic, catalase-negative coccobacillus that grows at 25, 35, and 42°C and is positive for esculin hydrolysis and arginine deamination (1). Originally identified as Lactobacillus confusus, the organism was reclassified into a novel genus in 1993 along with other lactobacilli and Leuconostoc paramesenteroides (2). Thus, this organism is frequently confused with Lactobacillus- or Leuconostoc-like organisms, which are inherently vancomycin resistant and often considered contaminants (3, 4). W. confusa has been isolated from sugar cane, carrot juice, milk, fermented cereals, and vegetables (5). Though an exceedingly rare human pathogen and usually nonfatal, W. confusa has been demonstrated to cause clinical disease such as abscess, bacteremia, prosthetic joint infection, and infective endocarditis (4, 6, 7, 8). Immunocompromised states, prior exposure to vancomycin, altered gut flora, recent gastrointestinal procedures, and TPN dependency are all suspected to be risk factors for the development of Lactobacillus species bacteremia (4). Due to the rarity of W. confusa, the Clinical and Laboratory Standards Institute (CLSI) has not established breakpoints for susceptibility testing. However, based on MICs, the preferred therapy includes penicillin, clindamycin, erythromycin, aminoglycosides, and imipenem (6). Daptomycin has also been shown to have activity, as was the case with our patient's isolate, which had a daptomycin MIC of 0.38 μg/ml by Etest (3). Though a rare entity, W. confusa should be considered for any patient presenting with bacteremia caused by a Gram-positive organism and underlying risk factors for infection with Lactobacillus species. Since vancomycin is the empirical first-line therapy for bacteremia caused by a Gram-positive organism, early consideration of this organism is important due to its inherent vancomycin resistance, which necessitates alternative therapy. (See page 759 in this issue [doi:10.1128/JCM.00941-13] for photo quiz case presentation.)